PREP U Chapter 72: Emergency Nursing
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Working in a chemical plant Swimming in a lake Running a race in hot humid weather Diving in an ocean
Correct response: Diving in an ocean Explanation: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Hypovolemia Sepsis Cardiac dysfunction Anaphylaxis
Correct response: Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
A client is admitted to the emergency department after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause? Concrete debris from an explosion Stabbing with a knife Impact of a steering wheel Fall to the ground from a ladder
Correct response: Stabbing with a knife Explanation: Penetrating abdominal injuries are ones involving an opening into the abdomen, such as those that occur with a gunshot or stabbing. Blunt injuries usually occur with motor vehicle crashes, falls, and explosions.
A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion? Tearing away of tissue from supporting structures Skin tear with irregular edges and vein bridging Incision of the skin with well-defined edges, usually longer than deep Denuded skin
Correct response: Tearing away of tissue from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? Red blood cell count of 50,000/mm3 Evidence of feces Absence of bile White blood cell count of 300/mm3
Correct answer: Evidence of feces
A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I need to avoid using perfumes and scented soaps when I'm going outside." "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still."
Correct response: "Brightly colored clothes help to ward off bees." Explanation: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.
The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following? "Do you want to discuss antipregnancy measures?" "Let's talk about this; do you want me to call a support person?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"
Correct response: "Let's talk about this; do you want me to call a support person?" Explanation: The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Performing a fasciotomy Splinting the wound in a position of rest to prevent motion Inserting an indwelling catheter Elevating the site to limit the accumulation of fluid in the interstitial spaces Applying a clean dressing to protect the wound
Correct response: Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Explanation: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey? Diagnostic and laboratory testing Undressing the patient Establishing a patent airway Assessment of peripheral pulses
Correct response: Delayed capillary refill Explanation: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Ask the ambulance team for information about the client's family to ensure informed consent. Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Explain to the client that care is going to be provided because he is seriously ill.
Correct response: Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.
Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Denial phase Reorganization phase Acute disorganization phase
Correct response: Heightened anxiety phase Explanation: During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? Dextrose 5% in water Type O negative blood Hypertonic saline Lactated Ringer's solution
Correct response: Lactated Ringer's solution Explanation: Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.
A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ? Duodenum Pancreas Large bowel Liver
Correct response: Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.
Acetaminophen overdose is treated with the administration of which of the following medications? Diazepam (Valium) N-acetylcysteine (Mucomyst) Naloxone (Narcan) Flumazenil (Romazicon)
Correct response: N-acetylcysteine (Mucomyst) Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? Flushed face Pinpoint pupils Hypertension Hyperventilation
Correct response: Pinpoint pupils Explanation: Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, descreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Using a sequence of four thrusts, each progressing in intensity Placing the thumb side of one hand at the xiphoid process Having the conscious client lie down Positioning the hands in the midline slightly above the umbilicus
Correct response: Positioning the hands in the midline slightly above the umbilicus Explanation: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage II Stage IV Stage I Stage III
Correct response: Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Induced vomiting Gastric lavage Dilution with water or milk Administration of activated charcoal
Correct response: Induced vomiting Explanation: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Apply a heat lamp. Administer an analgesic as ordered. Massage the extremities. Elevate the legs.
Correct response: Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
What is the most frequently injured solid organ in a penetrating trauma? Brain Lungs Liver Pancreas
Correct response: Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Assess and document any bruises and lacerations. Ensure that the police are present when the examination is performed. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Have the patient shower or wash the perineal area before the examination. Record a history of the event, using the patient's own words.
Correct response: Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Explanation: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Femoral Brachial Radial Subclavian
Correct response: Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. Increasing urine volume Decreasing blood pressure Increasing heart rate Delayed capillary refill Cool, moist skin
Correct response: Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Send the patient to the hyperbaric chamber. Send the patient for a chest x-ray. Ensure a patent airway and that the patient is receiving 100% oxygen. Draw labs for a chemistry panel.
Correct response: Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.
The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? Controlling hemorrhage. Establishing an airway. Obtaining consent for treatment. Restoring cardiac output.
Correct response: Establishing an airway. Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Knife-stab wound Fall from a roof Being struck with a baseball bat Motor-vehicle crash
Correct response: Gunshot wound Knife-stab wound Explanation: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Wheezing between coughs Forceful coughing High-pitched noise on inhalation Refusal to lie flat
Correct response: High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.
An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following? Immersion of the patient in a cold-water bath IV hydration with normal saline solution Endotracheal intubation with mechanical ventilation Administration of sodium supplements
Correct response: Immersion of the patient in a cold-water bath Explanation: For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer's solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Abdominal thrust Head tilt-chin lift Jaw-thrust Seldinger
Correct response: Jaw-thrust Explanation: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Massaging the feet Placing sterile cotton between the toes after rewarming Providing an analgesic for pain Restricting ambulation
Correct response: Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Measure the circumference of the arm. Administer cimetidine (Tagamet). Administer diphenhydramine (Benadryl). Assess peripheral pulses.
Correct response: Measure the circumference of the arm. Explanation: Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Gaining control of the situation Protecting himself or herself Providing care to the injured Securing the area
Correct response: Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.
A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? Pulmonary edema Head injury Hyponatremia Hypothermia
Correct response: Pulmonary edema Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.
A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? Do nothing because the nurse has no proof of wrongdoing. Try to convince the client to report the problem. Monitor the situation during subsequent visits. Report the suspicion to the local agency on aging within 24 hours of the visit.
Correct response: Report the suspicion to the local agency on aging within 24 hours of the visit. Explanation: The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Rinsing the area with copious amounts of water Administering tetanus prophylaxis Covering the area with a sterile dressing Applying antimicrobial ointment
Correct response: Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
Which of the following guidelines is appropriate to helping family members cope with sudden death? Inform the family that the patient has passed on Obtain orders for sedation for family members Show acceptance of the body by touching it, giving the family permission to touch Provide details of the factors attendant to the sudden death
Correct response: Show acceptance of the body by touching it, giving the family permission to touch Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as passed on. The nurse should avoid giving sedation to family members, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).
Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? Gallbladder Large intestines Liver Spleen
Correct response: Spleen Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Patterned Stab Avulsion
Correct response: Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Supporting the client's emotional status Obtaining consent for examination
Correct response: Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? Most multiple trauma victims exhibit evidence of the trauma. The most lethal injuries are often the most readily apparent. The client is assumed to have a spinal cord injury until proven otherwise. Injuries have occurred to at least three distinct organ systems.
Correct response: The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.
A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories? Psychological support Emergent Urgent Nonurgent
Correct response: Urgent Explanation: Patients triaged have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for patients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for patients who have episodic illness that can be addressed within 24 hours without increased morbidity. Patients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: heart rate. blood pressure. temperature. hemoglobin level.
Correct response: blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.